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(BWC Forms) - Injured Worker Forms Home
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Form Title
Description
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A-12
A.C.T. Enrollment and Direct Deposit Authorization
 
 
 
 
A-12-ES EFT
Formulario de inscripción y autorización de depósito directo de la ACT
 
 
 
 
A-21
Prepaid Debit Card Enrollment Application
 
 
 
 
A-21-ES
Tarjeta de débito prepagada
 
 
 
 
A-35
Direct Deposit ACT Bank Change
 
 
 
 
A-35-ES
Cambio de banco de depósito directo de ACT
 
 
 
 
C-5
Application for Death Benefits and/or Funeral Expenses
 
 
 
C-5-ES
Solicitud para los beneficios por fallecimiento y/o gastos funerarios
 
 
 
 
C-6
Application for Accrued Compensation
 
 
 
 
C-11
ADR Appeal to the MCO Medical Treatment/Service Decision
 
 
 
C-11-ES
Apelación a la decisión por servicio/tratamiento médico de la MCO de ADR
 
 
 
 
C-17
Request for Injured Worker Outpatient Medication Reimbursement
 
 
 
C-18
Notice to BWC of the Injured Worker and Employer Agreement and Authorization to Send Injured Worker's Check(s) to the Employer
 
 
 
C-23
Notice to Change Physician of Record
 
 
 
C-30
Request for Medical Information
 
 
 
 
C-32
Application for Payment of Lump Sum Advancement
 
 
 
C-60
Completing the Injured Worker Statement for Reimbursement of Travel Expense
 
 
 
C-60-A
Injured Worker Reimbursement Rates for Travel Expense
 
 
 
 
C-72
Consent to Release Information
 
 
 
 
C-72-ES
Autorización para divulgar información
 
 
 
 
C-77
Injured Worker's Change of Address Notification
 
 
 
C-84
Request for Temporary Total Compensation
 
 
 
C-84-ES
Petición de compensación total temporal
 
 
 
 
C-86
Motion
 
 
 
C-86-ES
Moción
 
 
 
 
C-92
Application for Determination or Increase of Percentage of Permanent Partial Disability
 
 
 
C-92-ES
para determinar el porcentaje de incapacidad parcial permanente o aumento de la incapacidad permanente parcial
 
 
 
 
Wages-IW
Injured Worker Earnings Statement
 
 
 
 
WAGES-IW-ES
Declaración de los ingresos del trabajador lesionado
 
 
 
 
Wages-EMP
Employer Report of Employee Earnings
 
 
 
 
Wages-EMP-ES
Informe del empleador de ingresos del empleado
 
 
 
 
C-101
Authorization to Release Medical Information
 
 
 
C-101-ES
Autorización para divulger información médica
 
 
 
 
ODM-10221
Standard Authorization Form
 
 
 
 
Instructions for completing the Standard Authorization Form
 
 
 
 
C-108
Waiver of Appeal
 
 
 
 
C-108-ES
Renuncia al período de apelación
 
 
 
 
C-140
Initial Application for Wage Loss Compensation
 
 
 
C-141
Wage Loss Statement for Job Search
 
 
 
C-142
Employer Report of Employee Earnings for Wage Loss Compensation
 
 
 
 
C-159
Waiver Of Workers' Compensation Benefits For Recreational Or Fitness Activities
 
 
 
C-159-ES
Renuncia a los beneficios por indemnización de los trabajadores para actividades recreativas o de ejercicios físicos
 
 
 
 
C-230
Authorization to Receive Workers' Compensation Check
 
 
 
C-230-ES
Autorización para recibir Cheques de compensación por accidentes en el trabajo
 
 
 
 
C-240
Settlement Agreement and Application for Approval of Settlement Agreement
 
 
 
 
C-255
Affidavit for Attorney Fees
 
 
 
 
C-261
Workers' Compensation Claim Log
 
 
 
 
C-265
Presumption of Causation for Firefighter Cancer
 
 
 
 
C-512
Notice of intent to Settle
 
 
 
 
FROI
First Report of an Injury, Occupational Disease or Death
 
 
 
FROI-ES
Informe inicial de lesión, enfermedad ocupacional o fallecimiento
 
 
 
 
Reporting fraud
 
 
 
 
IC-167-T
Objection to Tentative Order Awarding Permanent Partial Disability Compensation
 
 
 
 
MEDCO-31
Request for Prior Authorization of Medication Form
 
 
 
 
R-2
Claimant Authorized Representative
 
 
 
R-2-ES
Autorización de un representante del trabajador lesionado
 
 
 
 
R-4
Application for Representative Identification Number
 
 
 
 
RH-1
Rehabilitation Agreement
 
 
 
RH-6
On-the-job Training Agreement
 
 
 
RH-7
Loan/Release Agreement for Tool and Equipment
 
 
 
RH-10
Vocational Rehabilitation Plan Job Search Contacts
 
 
 
RH-18
Authorization for Living Maintenance Wage Loss
 
 
 
RH-24
Gradual Return to Work Agreement
 
 
 
RH-94A
Report of Earnings for Living Maintenance Wage Loss Compensation
 
 
 
 
SH-6
PERRP Complaint Form
 
 
 
 
SI-28
Filing of Allegation Against a Self-Insured Employer
 
 
 
SI-42
Self Insured Joint Settlement Agreement and Release
 
 
 
SI-43
Acknowledgement of the Self-Insured Joint Settlement Agreement and Release
 
 
 
Subrogation Referral Form